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Wednesday, April 4, 2012

Stuff I see on charts that drives me crazy

As I exist on the brink of extreme crankiness every day, it doesn’t take much to push me over the edge. Here are some things that do.

Why do history and physical write-up sound like transcriptions of interrogations? Specifically, why to doctors write, “Patient denies alcohol use”? It’s as if the patient has been accused of using alcohol and when she says she doesn’t drink, we say she “denies” it. In my experience, the vast majority of patients tell the truth during H&P interviews. There’s a difference between saying, “Patient doesn’t drink alcohol” and “The patient denies alcohol use.”

In reference to the examination of the head, eyes, ears, nose and throat, who is teaching medical students to write things like this?

“HEENT: normocephalic, atraumatic.”

With the exception of Joseph Merrick, known as “The Elephant Man,” just about every person I have ever seen is normocephalic. And other than those who have suffered an injury, the heads of most patients show no trauma.

It is important for a physician to know how to write a coherent sentence and spell words correctly. Poor spelling and grammar reflect either ignorance or sloppiness. Take the word “guaiac” for example. It refers to a reagent used less frequently now for the testing of the stool for blood. It is not spelled “guiac” or “guaic.” If you can’t spell it, use the word “heme” or simply say, “The stool test for blood was negative.”

Worst of all is misstating the plural of the word “diverticulum.” I have seen colorectal surgeons and gastroenterologists, both of whom should know better, refer to more than one diverticulum as “diverticuli” or “diverticulae.” Listen up, people. Diverticulum is derived from a Latin word. Its gender is neuter. Maybe you can remember it by considering other similar words: one bacterium, many bacteria; datum, data; stratum, strata.

49 comments:

I couldn't agree with you more about "denies;" however, I know that there are those patients who lie or don't tell whole truths. I suppose that "denies" is a CYA term.

Recently, I heard a great Grand Rounds podcast in which the speaker admonished students for saying "male" or "female" vs. "man" or "woman." Speaker would ask, "A 41-year-old male WHAT?" I thought it was a wonderful point that helped put the humanness back in being a patient.

That's true but there is a concept known as "charting by exception." If a child has craniosynostosis, I would mention it. The absence of a comment implies that the patient is normocephalic. This makes sense to me because about 99.9999% of people are normocephalic.

I would argue that spelling errors reflect the use of computers that correct them automatically. I have been writing almost exclusively on a computer for ~8 years, and it certainly shows in my spelling.

Why spend effort learning to spell when I have this convenient crutch? I know it looks bad, but I have so many more important things to worry about.

As an aside - they are not so much teaching us to write HEENT: NC/AT as they are telling us that we need to have a FULL physical exam documented. Which means that when I write a patient note and fill out the physical, I feel obligated to say SOMETHING in that section, even if their complaint is an upset stomach. It's obscene and stupid and I do it purely because at one point in my training someone told me I should have something in every section. That will absolutely go away when I can be in control of my own charting.

The best one I've seen recently is "Pt was a 30 week term baby." Really? Because I'm pretty sure 30 wk babies aren't considered term...unless you're a grizzly bear, then 30 wks would be considered about spot on.

I had a preceptor who would get upset about "regular rate and rhythm" because "regular rate" isn't a real thing according to her. A patient may have a regular heart rhythm, but their heart rate is either within or outside the limits of normal, it is not "regular." I don't know how much weight there is in that one, but she would get really annoyed at the triple-R charting.

Like this post, though. :) Agree with Afternoon about the alcohol, too - likely a CYA thing.

Danielle: Thanks for commenting. I think it's OK to ask students to write complete H&Ps. You will learn to edit as you go along. One can describe the head in many ways, but normocephalic is not a good choice. I agree about the 30 week term baby. Sinus rhythm is preferred over regular.

One problem to point out with "charting by exception:" Medicare coding guidelines.

I agree completely with you that charting by exception makes sense. Reading a 4 page note filled with lists of things the patient did not have, hoping to stumble on the important notations of what the patient DID have is far more efficient and far less error prone.

The problem is that Medicare coding guidelines require you to hit a defined number of "bullet points" to reach each level of service. As a result, you have notes that list an enormous amount of detail that is not relevant to the issue at hand, to satisfy coding guidelines at the expense of clarity and communication.

EHRs simply make this worse, by allowing each note to pull in every last spec of data that was ever collected for that patient into each and every note, regardless of how, when, or why that data was collected. Routinely I see 6, 7, 10 page notes describing a simple problem focused encounter.

Some years ago, I read a white paper that argued that medical records no longer serve their original purpose of documented and communicating a patient's medical history, and now a dual purpose as documents for accounting/billing and as legal documents in the malpractice suits.

I would agree that there are several things I see in charts that drive me a little crazy. However, I would also argue that many of these complaints can be short-sighted and obsessive. One should know how to spell, but lets face it we all screw up and if there isn't spell check right in front of us it'll happen again and again. I believe it's more important to actually know the patient and take an accurate history and physical than to have perfect spelling in the subsequent note.

You're entitled to your opinion, but I strongly disagree. Someone with 8 years of higher education should know how to spell the plural of diverticulum. To spell it wrong shows a lack of attention to detail, which is not a good trait for a physician.

I read five days of notes on a pt whose daily impression was "likely NSTEMI" - just as on admit. Enzymes, EKG's, echo, and a cath apparently didn't move that likelihood in either direction.

I cared about spelling until my first Blackberry showed me how much proper English slowed down the efficiency of my communication. Now I think of good spelling and grammar as having their place somewhere on a liberal arts campus. I don't care if my 5-yr-old ever learns you're from your. If she ever asks, I'll suggest ur. JK.

I've seen a few good copy and paste notes. Once I saw this as part of a note on two consecutive days:

"Patient had a tracheostomy today. No sign of bleeding."

Regarding spelling, I must disagree with you. It's one thing to type "ur" in a text. It's quite another to use it in an essay for college. Poor spelling and grammar hurts the credibility of a professional.

I have many pet peeves in incorrect use of terminology by people who should know better. At the top of the list is "regular rate and rhythm," which is used (along with its abbreviation RRR) even by cardiologists. A rate can be neither regular nor irregular. Regularity is a property of rhythm. A rate can be normal, fast, or slow. It can also be variable, but not irregular. As if the "oral tradition" perpetuating this were not bad enough, this phrase is included on the most widely used template charting system (which shall go unnamed, but you know which one that is).

While we're on the subject of proper singulars and plurals, let me exhort your readers to recall that one cannot have a pulmonary emboli (the singular is embolus) or a ureteral calculi (singular calculus). And even worse than the incorrect singular of nares (nare instead of the correct naris) is the occasional appearance of "diagnosises," which should be grounds for expulsion from medical school.On the positive side, I am always delighted when a trainee knows that the singular abbreviation is gt and the plural gtt (not gtt and gtts). If you really want to impress me, know the difference between nauseated and nauseous!

The Chief of Ophthalmology at my medical school didn't appreciate my pointing out that his letterhead, business cards and sign on the main door to department all had "Opthalmology" spelled wrong...no "l" in the middle. I wasn't going into Ophtamology anyways...:):):)

I love your blog but am sorry that I had not found it earlier. My problem with charting is the EMR as a whole which easily pulls all information forward whether it is current and correct or not. Unless there is active and meticulous editing the charting is incorrect and in my view can lead to poor patient care and probably errors. Our office EMR is not integrated with the hospital so our patients admitted in labor frequently are still on OCPs because no one actively updated the record. So small and yet so telling. "Old "paper charts required active charting, most EMR use is passive. My husband, a malpractice attorney, finds that the EMR does not help defend physicians because of the imprecision.

Anon, I agree about the updating of EMRs. It is particularly annoying with problem lists. They never are updated. Temporary issues like a UTI stay on them forever.

I agree that EMRs do not help with malpractice defense. When the records are printed, they are massive and filled with extraneous BS. Also, stuff the doc had never seen, like the voluminous tick box nurse charting, can contain damning information.

Regarding the spelling of the plural of diverticulum it would depend on the declination of the noun and what is being said: The latin genetive, accusative and dative, to mention 3 of the six, would all be different. Just for fun

I was just interviewed by a GP for an initial "meet & greet" as a new patient and when I answered that I don't drink alcohol he looked dubious and said something about Christmas coming and celebrations. I asked him if he thought I was lying...boy, did he backpedal! I was going to make a reference to him being Dr. House (who said everyone lies). (and yes, I really don't drink alcohol).

BTW I agree with knowing the difference between your & you're...if I ever encountered an english speaking doctor who misused them I would doubt their knowledge and list them as the "what do you call the person who came last in their medical class? Doctor" type person.

Everyone lies about alcohol use. I know this because I do too.Believing the patient tells the truth is a. VERY RISKY policy.The history is a STORY. Treat is as such: history is a contractionfor " his story"